Transcript Preoperative diagnostic algorithm in colon diverticular

Preoperative diagnostic algorithm
in colon diverticular disease
patrick ambrosetti
XXIV congresso nazionale dell’associazione
chirurghi ospedalieri italiani
florence may 2005
Presentation of the exposure
1. Set up about diagnosing suspected acute
diverticulitis:
- bioclinical evaluation
- CT compared to water-soluble contrast enema
2. In acute situation
3. After successful conservative management of the
first episode of acute diverticulitis
4. Where do we end up with elective colectomy?
Presentation of the exposure
1. Set up about diagnosing suspected acute
diverticulitis:
- bioclinical evaluation
- CT compared to water-soluble contrast enema
2. In acute situation
3. After successful conservative management of the
first episode of acute diverticulitis
4. Where do we end up with elective colectomy?
Acute diverticulitis: bioclinical diagnostic
approach
1. History and clinical examination
2. Temperature, CRP, white blood count
Acute diverticulitis: diagnostic approach
Temperature, white blood count and repartition:
temperature > 37.5
leucocytes > 11.000
left shift > 550
total
abscess
(542)
(69)
77%
50%
29%
85%
62%
29%
Acute diverticulitis: diagnostic approach
of 150 patients, prospectively evaluated, clinically
suspected of having acute diverticulitis only 64 (43%)
were proven so on CT.
Rao et al. Am J Radiol 1998; 170: 1445-49
of 120 patients clinically suspected of presenting acute
diverticulitis, only 67 (56%) had this diagnosis proven by
spiral CT
Werner et al. Eur Radiol 2003; 13: 2596-2603
In fact CT scan will confirm the diagnosis of acute
diverticulitis in only one of two patients bioclinically
suspected
Presentation of the exposure
1. Set up about diagnosing suspected acute
diverticulitis:
- bioclinical evaluation
- CT compared to water-soluble contrast enema
2. In acute situation
3. After successful conservative management of the
first episode of acute diverticulitis
4. Where do we end up with elective colectomy?
Compared performance of CT and GE*:
420 patients
(*gastrografin enema)
(p=0.0001)
CT
GE
N patients
420
420
Not diagnostic
18 (5%)
53 (13%)
Ambrosetti et al. Dis colon rectum 2000; 43: 1363-7
Compared performance of CT and GE:
sensitivity based on 136 operated patients (p=0.01)
True +
CT
GE
130 (96%)
121 (89%)
False +
4
4
False -
2
11
Sensitivity
98%
92%
Performance of GE in case of CT associated abscess
(69 patients (16%))
n patients
Severe GE
20 (29%)*
* Contrast extravasation 18
Diagnosis of diverticular abscess
CT is now universally recognized as the 1st
line morphological exam and has been
proven to be largely superior to contrast
enema study
Ambrosetti, Eur Radiol 2002; 12: 1145-9
Ambrosetti, Dis Colon Rectum 2000; 43: 1363-7
Lawrimore, J Intensive Care Med 2004; 19: 194-204
Buckley, Clin Radiol 2004; 59: 977-83
Presentation of the exposure
1. Set up about diagnosing suspected acute
diverticulitis:
- bioclinical evaluation
- CT compared to water-soluble contrast enema
2. In acute situation
3. After successful conservative management of the
first episode of acute diverticulitis
4. Where do we end up with elective colectomy?
CT in emergency situation
(42 patients)
Chances of medical treatment failure:
CT severe diverticulitis
(wait and see)
CT moderate diverticulitis
(wait and sit)
30%
4%
First episode of suspected acute diverticulitis
What are we looking for?
1. The confirmation of the diagnosis
2. The severity of the diverticulitis
What is the only tool to answer these questions
CT
(with oral, rectal and iv contrast)
How do we grade the severity of the
diverticulitis ?
Modified Hinchey Classification:
Stage 0: mild clinical diverticulitis
Stage Ia: confined pericolic inflammationphlegmon
Stage Ib: confined pericolic abscess
Stage II: pelvic, distant intraabdominal or
retroperitoneal abscess
Stage III: generalized purulent peritonitis
Stage IV: fecal peritonitis
Why the CT appreciation of severity?
A. To guide the therapeutic strategies:
1. Mild diverticulitis: conservative ambulatory care
(antibiotics?)
2. Stage Ia: conservative care with oral antibiotics
3. Stage Ib and II: hospitalization, iv antibiotics, eventual CT
drainage, possible surgery
4. Stage III and IV: surgery
B. To evaluate the chances of secondary bad outcome
after a first episode of acute diverticulitis
susccessfully treated conservatively
So, where is the challenge ?
The existence of an associated abscess
Why ?
1. Frequent (between 15 to 20%)
rao et al. am j radiol 1998
ambrosetti et al. eur radiol 2002
werner et al. eur radiol 2003
2. Difficult to diagnose bioclinically
3. Therapeutically challenging
Types of acute treatment
Should we drain ?
« …small pericolic abscess may resolve with
antibiotic therapy and bowel rest… »
« …today the decision to drain remains to be
individualized 1 »
1. The Standard Task Force and the American Society of Colon and
Rectum Surgeons, Dis Colon Rectum 2000; 43: 289-97
Secondary treatment
1. « Recently, some surgeons have suggested that surgical
resection may not be mandatory in every case after
successful percutaneous drainage: however, at present
there are insufficient data to support universal
endorsement of this concept »
The Standard Task Force and the American Society of Colon and Rectum
Surgeons, Dis Colon Rectum 2000; 43: 289-97
2. « …do a percutaneous drainage where possible, followed
later by sigmoid resection in most cases… »
European Association of Endoscopic Surgery, Surg Endosc 1999; 13: 430-6
Abscess associated to diverticulitis
• Between october 1986 to october 1997:
– 465 patients had a CT evaluation
– 76 (16.3%) had an associated mesocolic or
pelvic abscess
– 73 patients could be followed-up
– Median follow-up: 43 months (2 – 180)
– 26 women and 47 men with a mean age of 68
(30 – 94)
Ambrosetti et al. Dis colon rectum, march 2005
Abscess associated to diverticulitis
• Therapeutic principles:
– Percutaneous CT drainage of abscess were done
only if no bioclinical improvement were noted
after 48 hours of parenteral antibiotics
– Elective colectomy after successful
conservative management of the abscess was
not an absolute indication and was adapted for
each patient
Associated abscess
Location and CT percutaneous drainage
n
drained
(%)
Mesocolic
Pelvic
45
28
11 (24)
8 (29)
not drained
(%)
34 (76)
20 (71)
Surgical vs conservative treatment:
no op.: conservative treatment
op. 1: surgery during 1st hospitalisation
op. 2: surgery later on
N
No op.
(%)
Op. 1
(%)
Op. 2
(%)
mesocolic
45
22 (49)
7 (15)
16 (36)
Pelvic
28
8 (29)
11 (39)
9 (32)
Long-term evolution
1. No patient needed an emergency surgical
treatment
2. 15 patients (21%) died during the course of the
follow-up. No one died from complications
related to the diverticular disease
Essential findings
1. Initial CT is indispensable to confirm the diagnosis and
precise the severity of the diverticulitis
2. Patients with a pelvic abscess should be immediately
drained
3. Mesocolic abscess ≥ 5 cm should probably be drained
immediately
4. Secondary colectomy after pelvic abscess seems highly
reasonnable
5. Secondary colectomy after successful conservative
treatment of mesocolic abscess is probably not
mandatory for all patients
Presentation of the exposure
1. Set up about diagnosing suspected acute
diverticulitis:
- bioclinical evaluation
- CT compared to water-soluble contrast enema
2. In acute situation
3. After successful conservative management of the
first episode of acute diverticulitis
4. Where do we end up with elective colectomy?
Acute left colonic diverticulitis
Prospective study
October 1986 – October 1997
University Hospital Geneva
Acute diverticulitis: prospective study
542 patients
290 women and 252 men
Mean age: 64 (23-97)
Acute diverticulitis: profile of the study
Patients included:
1. Clinical and history compatibility
2. Radiological confirmation (CT and watersoluble contrast enema=GE)
3. Histological diagnosis
4. 1st hospital admission
Patients excluded:
No radiological or histological confirmation
Acute diverticulitis: radiological criteria
(CT and GE)
Moderate diverticulitis
Severe diverticulitis
CT: localized wall thickening The same + at least one of the
(>=5mm)
following:
Inflammation of pericolic fat
Abscess
Extraluminal air/ contrast
GE: segmental lumen
narrowing
Tethered mucosa
+/- mass effect
The same + at least one of the
following:
Extraluminal air/ contrast
Acute diverticulitis
Long-term follow-up after a 1st acute
episode of left colonic diverticulitis:
is surgery mandatory ?
R. Chautems, P. Ambrosetti, C. Soravia
American Society of Colorectal Surgeons
San Diego, June 2001
Dis Colon Rectum 2002; 45: 962-966
Acute diverticulitis: aims of the study
• To evaluate on a long term (9.5 years) the
outcome of 118 patients treated medically
with success for a 1st episode of
diverticulitis
• To determine risk factors of poor evolution
• To assess the place of surgery
• To propose a timing for surgery
Acute diverticulitis:
Post hospitalisation evolution
No complications: 80 patients (68%)
Evolutive complications: 38 patients (32%)
24 deaths (20%)
21 not related to diverticular disease
No emergency operation
Identification of initial parameters
predictive of evolutive complications
Age
Severity of the inflammation on CT
Presentation of the exposure
1. Set up about diagnosing suspected acute
diverticulitis:
- bioclinical evaluation
- CT compared to water-soluble contrast enema
2. In acute situation
3. After successful conservative management of the
first episode of acute diverticulitis
4. Where do we end up with elective colectomy?
Acute diverticulitis: indication for
elective colectomy
EAES: after 2 episodes of symptomatic diverticular
disease
ASCRS: after 2 episodes of uncomplicated
diverticular disease (phlegmon), but maybe
recommended after a single attack of complicated
diverticulitis
ACGE: recurrent attacks, complicated disease
(abscess or fistula). After 1 episode in young and
immunocompromised patients
So, what is the medical evidence to
sustain such a proposition ?
1. For the ASCRS (American Society of Colon and Rectal Surgeons)
Dis Colon Rectum 2000; 43: page 293 « resection after
recurrent attacks of diverticulitis »:
« … with each recurrent episode the patient is less likely to to
respond to medical therapy (70 percent chance of response to
medical therapy after the 1st attack vs. 6 percent chance after the
third) (ref. 65) »
Reference 65…
Parks TG. Natural history of diverticular disease of
the colon. A review of 521 cases. BMJ 1969; 4:
639-642
What is the profile of this study?
Retrospective study of 521 patients (455 treated as inpatients)
Royal Victoria Hospital, Belfast
1951 – 1965
Results of conservative treatment
(317 patients)
78 (25%) were readmitted for a 2nd attack
12 (3.8%) for a 3rd one
5 (1.6%) for a 4th one
1st admission: 3.3% mortality (mostly post-surgical)
1st recurrence: 7.7% mortality
Conclusion: « medical treatment of recurrent
disease was less rewarding than treatment of
the presenting attack… »
Critical reviewing
1. The diagnostic accuracy is weak and considerably
increase the probability of false positive
2. 13 (17%) of the 78 patients with recurrent attacks were
readmitted between 0 and 3 months after their
discharge
3. Post-surgical and post-medical mortality are not
precised
4. It seems that only one patient (8%) of the 12 patients
who had more than one recurrence died, so the
mortality after more than 2 attacks is not greater than
after 2 attacks
Then, what would be the reasons to propose elective
colectomy ?
I see 2 good reasons:
1. The evidence that after acute diverticulitis
successfully treated medically the risk of
spontaneous evolutive morbidity/ mortality is
greater than the one related to elective surgery
2. The persistance of symptoms not responding to
conservative means clearly related to diverticular
disease
So…is nature better than surgeon ?
A presently asymptomatic patient is sent to you for
sigmoidectomy because he (or she) had more than 2
episodes of CT-proven acute diverticulitis
how should you advise the patient?
No scientifically demonstrated answer
No evidence to support the idea that elective
surgery should follow two attacks of
diverticulitis…!
Medline search of english literature
Janes et al. Br J Surg 2005; 92: 133-142
Diagnostic algorithm
bioclinically suspected diverticulitis
clinical diffuse peritonitis
emergency surgery
localized signs
CT
Mild inflam. mesocolic abcess mesocolic abscess pelvic abscess
(< 5cm)
(> 5cm)
Oral AB
iv AB
iv AB+drainage iv AB+drainage
drain if failure
surgery if failure
after 48 h
Secondary treatment
What are the scientific evidences to sustain
such a proposition:
none !
So, what is the medical evidence to
sustain such a proposition ?
2. For the American College of Gastroenterology:
same reference of Parks’study
But mentioned that this recommandation of elective
resection after 2 attacks has been questioned by Lorimer
Is prophylactic resection valid as an indication
for elective surgery in diverticular disease?
Lorimer Can J Surg 1997
Retrospective study of 154 patients with complicated DD
(perforation, fistula and obstruction)
1987 – 1995
Only 10% of these 154 patients had been treated
conservatively for acute diverticulitis and only 5% had
been hospitalized for this reason
Conclusions: interval prophylactic resection in patients
after 1 or 2 episodes of diverticulitis is unlikely to
prevent late major complications of DD
Acute diverticulitis: risk of error
on bioclinical ground
Moreaux (br j surg 1990): on 72 patients with
chronic symptoms: 25 (35%) had an
associated abscess!
on the contrary
Morson (clin gastroenterol 1975): one third of
the patients operated on for diverticulitis
had no histological acute inflammation!
Acute diverticulitis:
postcolectomy functional results
Breen (dis colon rectum 1986): 27% of 89 patients
with a 37 months follow-up had postcolectomy
persistant symptoms!
Good results were related to:
1. Histological signs of acute inflammation
2. Male
3. Symptoms < 1 year
4. Pain in left lower quadrant
5. Radiological confirmation
Consensus on diverticular disease
1. EAES European Association for Endoscopic
Surgery, Rome, June 1998
surg endosc 1999; 13: 430-436
2. ASCRS the American Society of Colon and
Rectal Surgeons
dis colon rectum 2000; 43: 289-297
3. ACGE the American College of
Gastroenterology
am j gastroenterol 1999; 94: 3110-3121
Acute diverticulitis: initial evaluation
EAES: CT
ASCRS: clinical ground or CT, watersoluble contrast enema or us depending
on severity of the disease
ACGE: clinical ground or CT
CT and diverticulitis
1. Generalities
2. Presentation of the study
3. Compared performance with water-soluble
enema (GE)
4. Prognostic value in acute setting
5. Prognostic evolutive value after 1st episode of
diverticulitis successfully treated conservatively
6. Conclusion
CT and diverticulitis
1. Generalities
2. Presentation of the study
3. Compared performance with water-soluble
enema (GE)
4. Prognostic value in acute setting
5. Prognostic evolutive value after 1st episode of
diverticulitis successfully treated conservatively
6. Conclusion
Presentation of the exposure
1. About diagnosis
2. 2005 elective indications
3. Geneva Prospective Study:
- presentation
- long-term evolution after a 1st acute attack
treated conservatively
- evolution of mesocolic and pelvic
associated abscesses
4. Conclusions
What is the nature of the commonly accepted
surgical aggressiveness ?
1. Famous frightening doctors:
1. Colcock (Lahey Clinic)
N Engl J Med 1958; 259: 570-3
2. Keighley (Queen Elizabeth Hospital, Birmingham)
Br J Surg 1994; 81: 733-5
3. Irvin (Royal Devon and Exeter Hospital, UK)
Br J Surg 1997; 84: 535-9
2. Coelioscopic surgery
From where is coming the new wind of
surgical moderation ?
From part of the literature that did not confirm the
announced fate of secondary perforation after
conservative treatment of the first acute attack:
1. Larson Gastroenterology 1976; 71: 734-737
2. Simonowitz Am J Gastroenterol 1977; 67: 69-72
3. Haglung Ann Chir Gyneacol 1979; 68: 41-46
4. Nylamo Ann Chir Gyneacol 1990; 79: 139-142
5. Vignati Dis Colon Rectum 1995; 38: 627-32
and…
And…
4. Guzzo, Hyman Dis Colon Rectum 2004; 47: 1187-90:
259 patients < 50 y.o. with a median followup of 5.2 years
Of 196 who were conservatively treated,
only one (0.5%) presented at a later date with
perforation
Indications for elective colectomy
American and European Consensus unanimously
agree that elective colectomy is indicated after 2
attacks of acute diverticulitis
1. EAES European Association for Endoscopic Surgery, Rome, June
1998
Surg Endosc 1999; 13: 430-436
2. ASCRS the American Society of Colon and Rectal Surgeons
Dis Colon Rectum 2000; 43: 289-297
3. ACGE the American College of Gastroenterology
Am J Gastroenterol 1999; 94: 3110-3121
Recurrence after a 1st episode of acute
diverticulitis treated conservatively
Elements of reflection…
1. Are there initial predictive factors ?
2. How severe can the recurrence be ?
Presentation of the exposure
1. About diagnosis
2. 2005 elective indications
3. Geneva Prospective Study:
- presentation
- long-term evolution after a 1st acute attack
treated conservatively
- evolution of mesocolic and pelvic
associated abscesses
4. Conclusions
Presentation of the exposure
1. About diagnosis
2. 2005 elective indications
3. Geneva Prospective Study:
- presentation
- long-term evolution after a 1st acute attack
treated conservatively
- evolution of mesocolic and pelvic
associated abscesses
4. Conclusions
Presentation of the exposure
1. About diagnosis
2. 2005 elective indications
3. Geneva Prospective Study:
- presentation
- long-term evolution after a 1st acute attack
treated conservatively
- evolution of mesocolic and pelvic
associated abscesses
4. Conclusions
Abscess associated to diverticulitis
P. Ambrosetti, R. Chautems, Cl. Soravia
• From October 1986 to October 1997:
– 465 patients had a CT evaluation
– 76 (16.3%) had an associated mesocolic or
pelvic abscess
– Median follow-up of 43 months for 73 patients
to july 2002
– 47 women and 26 men with a mean age of 68
(24 – 94)
Abscess associated to diverticulitis
• Therapeutic principles:
– Percutaneous CT drainage of abscess were done
only if no bioclinical improvement were noted
after 48 hours of parenteral antibiotics
– Elective colectomy after successful
conservative management of the abscess was
not an absolute indication and was adapted for
each patient
Surgical vs conservative treatment:
no op.: conservative treatment
op. 1: surgery during 1st hospitalisation
op. 2: surgery later on
N
No op.
(%)
Op. 1
(%)
Op. 2
(%)
mesocol
45
22 (49)
7 (15)
16 (36)
pelvic
28
8 (29)
11 (39)
9 (32)
Essential findings
• 1. Initial CT is indispensable to precise the
severity of the diverticulitis, and help the
physician to choose the best immediate and late
therapeutic options
• 2. After a first attack of diverticulitis
succesfully treated conservatively,
diverticular perforation with generalized
peritonitis is an exceptional type of
recurrence
Acute diverticulitis: conclusions 1
After a 1st episode of diverticulitis successfully treated
conservatively:
A. Elective colectomy could be proposed for:
1. Patients ≤ 50 year old with a CT severe
inflammation
2. Patients with a pelvic abscess (which should always be
drained first and operated later on)
Acute diverticulitis: conclusions 2
B. Mesocolic abscess ≥ 5 cm should probably be drained
immediatly
C. Secondary colectomy after successful conservative
treatment of mesocolic abscess is probably not mandatory
for all patients…
D. A trial of high fiber diet for the other patients seems
reasonable
Results after elective coelioscopic sigmoidectomy
Prospective series of 50 patients operated electively
laparoscopically between 1998 and 2005
All diverticulitis were CT proven
Indications to sigmoidectomy:
after 1 CT severe attacks in young patients
after 2 attacks
Questionnaire sent in March 2005:
36 patients already answered
Mean follow-up: 39.5 mois
Postoperative abdominal pain
Group 1 = No abdominal pain: 19 (53%)
Group 2 = Abdominal pain not existing
before the operation: 9 (25%)
Group 1 vs group 2: properative bowel function (BF)
No abd. Pain (19)
Abd. Pain (9)
Normal preop. BF
15 (79%)
6 (67%)
Diarrhea
0
0
Constipation
3
2
Alternation constipationdiarrhea
1
1
Group 1 vs group 2: length of resected sigmoid
No difference:
24.3 cm (15-45) vs 24.2 cm (16-50)
Group 1 vs group 2 vs bowel function
1stool/2-3 days
1-2 stools/D
>2stools/D
>5 stools/D
Normal stools
Soft stools
Hard stools
Alternation hard-soft
Metamucil
Laxatives
No abd. Pain (19)
2
13 (68%)
4
0
9 (47%)
2
0
8 (42%)
11 (58%)
0
Abd. Pain (9)
0
4 (44%)
4
1
2 (22%)
1
0
6 (67%)
0
1
How does abdominal pain impact on the general impression of the patient?
BF=bowel function FR=final result
No abd. Pain (19)
Postop. BF better
13 (68%)
Postop BF idem
5
Postop BF worse
1
FR good to excellent
15 (79%)
FR satisfying
4
FR poor
FR very poor
Would you do again the
19 (100%)
operation
Would you not do it again
Abd. Pain (9)
3 (33%)
5
1
1 (11%)
5
2
1
7 (78%)
2
The last parutions in literature
1. The value of CT:
Ambrosetti et al. Eur Radiol 2002; 12: 1145-1149
2. When and who to operate:
Chautems, Ambrosetti, Soravia et al. Dis Colon Rectum
2002; 45: 962-966
3. Long-term outcome of mesocolic and pelvic
diverticular abscesses of the left colon. A prospective
study of 73 cases
Ambrosetti, Chautems, Soravia et al. Dis Colon Rectum,
sous presse
Geneva prospective study:
last informations…
• 1. When and who to operate:
Chautems, Ambrosetti, Soravia et al. Dis
Colon Rectum 2002; 45: 962-966
• 2. The value of CT:
Ambrosetti et al. Eur Radiol 2002; 12:
1145-1149
• 3. Left colonic diverticulitis: long-term
evolution of associated mesocolic and pelvic
abscesses
Ambrosetti, Chautems, Soravia et al.
under study
Associated abscess
• Multivariate analysis under study:
– Location
– Size
– Drainage or no drainage
– Sex
– age
Acute diverticulitis: important findings
On a long term follow-up after successful
conservative treatment of a 1st episode of
left colonic diverticulitis:
no death from the disease
no emergency surgery
Consensus on diverticular disease
1. EAES European Association for Endoscopic
Surgery, Rome, June 1998
Surg Endosc 1999; 13: 430-436
2. ASCRS the American Society of Colon and
Rectal Surgeons
Dis Colon Rectum 2000; 43: 289-297
3. ACGE the American College of Gastroenterology
Am J Gastroenterol 1999; 94: 3110-3121
Acute diverticulitis: initial evaluation
EAES: CT
ASCRS: clinical ground or CT, watersoluble contrast enema or us depending
on severity of the disease
ACGE: clinical ground or CT
Associated abscess
N
Meso non op
Diameter
(cm)
22
Drained
(%)
Not
drained
(%)
4.3 (0.5-
5/22
(23)
17/22 (77)
17/23 (74)
8)
Meso op
23
4.7 (2-13)
6/23
(26)
Pelvic non
op
8
5.4 (2-9)
4/8
Pelvic op
20
5.5 (2-9)
4/20
(20)
(50)
4/8 (50)
16/20 (80)
Acute diverticulitis: diagnostic approach
Temperature, white blood count and repartition:
total
(542)
temperature > 37.5
leucocytes > 11.000
left shift > 550
77%
50%
29%
abscess
(69)
85%
62%
29%
Acute diverticulitis: risk of error on
bioclinical ground
Moreaux (Br J Surg 1990): on 72 patients
with chronic symptoms: 25 (35%) had an
associated unsuspected abscess!
on the contrary
Morson (Clin Gastroenterol 1975): one
third of the patients operated on for
diverticulitis had no histological acute
inflammation!
Acute diverticulitis: postcolectomy
functional results
Breen (Dis Colon Rectum 1986): 27% of 89 patients
with a 37 months follow-up had postcolectomy
persistant symptoms!
Good results were related to:
1. Histological signs of acute inflammation
2. Male
3. Symptoms < 1 year
4. Pain in left lower quadrant
5. Radiological confirmation
Acute diverticulitis: priority
• During the 1st suspected episode of acute
diverticulitis:
immediate and later therapeutic
strategies depend of the quality of the
initial evaluation
Acute diverticulitis
1. Radiological investigations: which ones?
2. Elective surgery: who? when?
Drainage related to size and location of the abscess
Mean size Mean size
mesocol
pelvic
(cm)
(cm)
size≥5c
Mesocol
size≥5c
Pelvic
Drained
6.8 (3.513)
6.6 (4-9)
8/11
(73%)
7/8 (88%)
Not
drained
3.8 (0.5-8)
5 (1-9.5)
12/34
(35%)
P=0.03
10/20
(50%)
P=0.07
Acute diverticulitis: bioclinical diagnostic
approach
1. History and clinical examination
2. Temperature, CRP, white blood count
Age : p = 0.007
Age
Nb
No complic
Complic
≤ 50
27
12 (44%)
15 (56%)
> 50
91
68 (75%)
23 (25%)
CT severity: p = 0.003
Severity
No complication
Complication
30 severe
14 (47%)
16 (53%)
88 mild
66 (75%)
22 (25%)
Associated abscess: drainage
n
Mesocolic
Pelvic
45
28
drained
not drained
(%)
(%)
11 (24)
8 (29)
34 (76)
20 (71)
Reflection about natural evolution of diverticular
disease after a 1st episode of acute diverticulitis
1. In 2004 diagnosis and signs of severity of acute
diverticulitis can only be precised on a CT scan
2. The study of natural evolution of diverticular
disease after a 1st episode of acute diverticulitis
has to be based on the prognostic value of CT
signs grading the severity of the inflammation
3. Bias of the patients treated conservatively is
related to the poorly defined indications for
surgery
Acute diverticulitis: patients and methods
118 patients (1986-1991)
59 women and 59 men
Median age: 63 (23-93)
Median follow-up: 9.5 years (0.2-13.8)
Follow-up:
Rehospitalisation (s)
Questionnaires to patients and/ or physicians
Age and CT severity
Complication
No
complication
Age/severity
Nb
≤ 50 moderate
14
6 (43%)
8 (57%)
≤ 50-severe
13
9 (69%)
4 (31%)
>50
moderate
74
16 (22%)
58 (78%)
> 50-severe
17
7 (51%)
10 (59%)
Introduction
1. Diverticular disease along the time:
1.1. rate of hospital admission in England
1.2. Incidence of perforated colonic diverticular disease
2.
1.1. Hospital admissions in England between
1989/ 1990 and 1999/ 2000
kang et al. Aliment Pharmacol Ther 2003
1. Increase of annual age-standardized hospital
admissions:
16% for males
12% for females
2. Increase of rates of operations at 1st admission:
16% fro males
14% for females
3. No change in population mortality
1.2. Incidence of perforated colonic diverticular
disease (PCDD)
The incidence rate of PCDD seems to increase over
these last years:
1.1. the annual prevalence in Northern Finland went from
2.4 per 100.000 in 1986 to 3.8 per 100.000 in 2000
dis colon rectum 2002
1.2. In Texas, San Antonio Hospital, it is reported a 75%
increase in the rate of emergency operations for PCDD over
a 15-year period
arch surg 2000
2. Risk factors of PCDD
2.1. The strongest and most consistent evidence in case
series and case-control studies is the NSAID use
bmj 1985 / bmj 1987 / br j surg 1990 / br j surg 1991 / ann r
coll surg engl 2002
2.2. Long-term or high steroid-dose
am j surg 1971 / arch surg 1991 / ann thorac surg 1996 / j
heart lung transplant 1997
2.3. Opiate analgesics
br j surg 2003
2.4. Diet fiber deficiency
gut 1985 / am j clin nutr 1994
3. Prevention of complications of colonic
diverticulosis
3.1. high fiber diet
3.2. sequential oral antibiotics
3.3. calcium channel blockers
3.1. High fiber diet
A high fiber diet, poor in total fat and red meat in
association with regular physical training could play a
role in preventing complications of diverticulosis
1. Hyland et al. Does a high fibre diet prevent the complications of diverticular
disease? Br J Surg 1980; 67: 77-9
2. Painter NS. Diverticular disease of the colon: the first of the Western diseases
shown to be due to a deficiency of dietary fibers. S Afr Med J 1982; 61: 1016-20
3. American Medical Association, Council on Scientific Affairs. Dietary fiber
and health: Council report. JAMA 1989; 262: 542-6
4. Aldoori et al. A prospective study of alcohol, smoking, caffeine, and the risk
of symptomatic diverticular disease in men. Ann Epidemiol 1995; 5: 221-8
5. Aldoori et al. A prospective study of dietary fiber types and symptomatic
diverticular disease in men. J Nutr 1998; 128: 714-9
6. Aldoori, Ryan-Harshman. Preventing diverticular disease. Canadian Family
Physician, octobre 2002, p. 1 à 8
3.2. Sequential oral antibiotics +/- 5-ASA
Beneficial effect of sequential oral rifaximin +/associated with mesalazine on symptomatic or
recurrent diverticular disease
1. Papi et al. Efficacy of rifaximin on symptoms of uncomplicated
diverticular disease of the colon. A pilot multicenter open trial. Diverticular
Disease Study Group. Ital J Gastroenterol 1992; 24: 452-6
2. Papi et al. Efficacy of rifaximin in the treatment of symptomatic
diverticular disease of the colon. A multicentre double-blind pacebocontrolled trial. Aliment Pharmacol Ther 1995; 9: 33-9
3. Trespi et al. Therapeutic and prophylactic role of mesalazine (5-ASA) in
symptomatic diverticular disease of the large intestine: 4 year follow-up
results. Minerva Gastroenterol Dietol 1999; 45: 245-52
4. Tursi et al. Long-term treatment with mesalazine and rifaximin vs
rifaximin alone for patients with recurrent attcks of acute diverticulitis of
colon. Digest Liver Dis 2002; 34: 510-15
3.3. Calcium channel blockers
A recent case-control study seems to show for the
first time that a protective association exists
between calcium channel blockers and PCDD
morris et al. gut 2003
Results of elective colectomy
1. Recurrence
2. Functional results
1. Recurrence
Level of anastomosis (colosigmoid or colorectal) is
the only recognized predictor of recurrence
which varies from 4 to 8%
1. Benn et al. Level of anastomosis and recurrent colonic
diverticulitis. Am J Surg 1986; 151: 269-71
2. Bergamaschi et al. Anastomosis level and specimen length in
surgery for uncomplicated diverticulitis of the sigmoid. Surg
Endosc 1998; 12: 1149-51
3. Thaler et al. Determinants of recurrence after sigmoid
resection for uncomplicated diverticulitis. Dis Colon Rectum
2003; 46: 385-88
2. Persisting symptoms
Its incidence varies from 20 to 27%
1. Breen et al. Are we really operating on diverticulitis?
Dis Colon Rectum 1986; 29: 174-6
2. Munson et al. Diverticulitis: a comprehensive followup. Dis Colon Rectum 1996; 39: 318-22
3. Stevenson et al. Laparoscopic assisted anterior
resection for diverticular disease: follow-up of 100
consecutive patients. Ann Surg 1998; 227: 335-42
4. Thörn et al. Clinical and functional results after
elective colonic resection in 75 consecutive patients with
diverticular disease. Am J Surg 2002; 183: 7-11
2. Persisting symptoms: etiology
1. Limited sigmoid resection
Munson et al. Diverticulitis: a comprehensive follow-up. Dis Colon
Rectum 1996; 39: 318-22
2. No histological inflammation on the specimen
Breen et al. Are we really operating on diverticulitis? Dis Colon
Rectum 1986; 29: 174-6
3. Functional history of « irritable bowel syndrome »
Stevenson et al. Laparoscopic assisted anterior resection for
diverticular disease: follow-up of 100 consecutive patients. Ann
Surg 1998; 227: 335-42
Thörn et al. Clinical and functional results after elective colonic
resection in 75 consecutive patients with diverticular disease. Am J
Surg 2002; 183: 7-11
Presentation of the exposure
1.
2.
3.
4.
Introduction
Bioclinic approach of acute diverticulitis
Elective colectomy: long-term results
Open vs laparoscopic sigmoidectomy: the same
operation?
5. Geneva Prospective Study:
- presentation
- long-term evolution after a 1st acute attack treated
conservatively
- evolution of mesocolic and pelvic associated
abscesses
6. Conclusions
3. Colectomie conventionnelle et
coelioscopique: la même opération?
What do we know about the operative quality of
laparoscopic colectomy compared to open
one?
Recurrence rates at minimum 5-year follow-up:
laparoscopic vs open sigmoid resection for
uncomplicated diverticulitis
Klaus, Wexner et al. Surg Laparosc Percutan Tech 2003;
325-327
Klaus, Wexner et al.
Retrospective study with prospective data
Two institutions (France and US)
79 comparable patients in each group
Conversion rate 6%
No mortality
No anastomotic leaks
Significant differences
Variable
Laparoscopic
N=79 (%)
Open
N=79 (%)
P
Splenic angle
down
19 (24)
41 (52)
0.001
Specimen
length
16.1+/-5.5
18.3+/-4.1
0.043
Inflammed prox.
Resection
margin
21 (27)
4 (5)
0.001
Taenia at distal
resection
margin
4 (5)
53 (70)
0.001
Does it influence recurrence rate?
NO !
3 (4%) for laparoscopy vs 7 (10%) for open
Presentation of the exposure
1.
2.
3.
4.
Introduction
Bioclinic approach of acute diverticulitis
Elective colectomy: long-term results
Open vs laparoscopic sigmoidectomy: the same
operation?
5. Geneva Prospective Study:
- presentation
- long-term evolution after a 1st acute attack treated
conservatively
- evolution of mesocolic and pelvic associated
abscesses
6. Conclusions
Criteria of selection
1. Diagnosis of diverticular disease (DD) :
clinical features + one or both of the following:
1. Radiological evidence of diverticula or deformity consistent with
DD
2. Confirmation of the presence of diverticula or of local
inflammatory involvement of the colon consistent with DD at
operation or necropsy
2. Diagnosis of diverticulitis:
clinical findings of inflammation (tenderness, pyrexia, mass, leucocytosis)
radiological changes consistent with inflammatory involvement
histological confirmation of inflammation (operation or necropsy)
Characteristics of the cohort
1. 426 patients had a final diagnosis of diverticulitis
95 (18%) had an inconclusive diagnosis
2. 461 have a barium enema:
230 had the diagnosis of diverticulosis
231 had the diagnosis of diverticulitis (performance of 59%)
3. Only 198 (38%) had a normal bowel habit before the
diverticulitis
4. 119 (23%) had a frank bleeding
Results on the 455 in-patients
138 (30%) had surgical treatment during their 1st admission or shortly
after
Of the 317 patients treated conservatively:
78 (25%) were readmitted for a 2nd attack
12 (3.8%) for a 3rd one
5 (1.6%) for a 4th one
Mortality during 1st admission was 3.3% (15 of 455 patients, mostly postsurgical)
Mortality of the 1st recurrence was 7.7% (6 of 78 patients) so twice that
of the presenting attack
Conclusion: « medical treatment of recurrent disease was less
rewarding than treatment of the presenting attack… »
Types of acute treatment
1. Parenteral antibiotics alone
2. Parenteral antibiotics + Drainage:
2.1. percutaneous CT-guided
Neff, Radiology 1987; 163: 15-8
Mueller, Radiology 1987; 164: 321-5
Stabile, Am J Surg 1990; 159: 99-104
Van Sonnenberg, World J Surg 2001; 25: 362-72
2.2. transrectal
Finne, Dis Colon Rectum 1980; 23: 293-7
2.3. Transcolonic under EUS
Baron, Gastrointest Endosc 1997; 45: 84-7
Attwell, Gastrointest Endosc 2003; 58: 612-616
2.4. Laparoscopically
Franklin, Surg Endosc 1997; 11: 1021-5
Drainage related to size and location of the abscess
Mean
size
mesocol
Mean
size
pelvic
size≥5cm
Mesocol
size≥5cm
Pelvic
(cm)
(cm)
Drained
6.8 (3.513)
6.6 (4-9)
8/11
(73%)
7/8 (88%)
Not
drained
3.8 (0.58)
5 (1-9.5)
12/34
(35%)
P=0.03
10/20
(50%)
P=0.07
Diagnostic value of CT for suspected diverticulitis
authors
Sensitivity Specificity
PPV
NPV
Accuracy
Alternativ
diagnosis
seen (%)
Cho
93
100
NA
NA
NA
69
Stefansson
69
100
NA
NA
NA
NA
Pradel
91
77
81
88
84
50
Rao
97
100
100
98
98
58
Ambrosetti
98
NA
97
Na
NA
NA